Second provincial inspection raises more allegations of abuse at Shalom Village

A second provincial inspection of Shalom Village again raises allegations of abuse, delays in reporting and insufficient background checks of staff.

It also accuses the Westdale long-term care home of failing to properly report an unexpected death.

In addition, the inspector alleges Shalom Village did too little to prevent an altercation between two residents that resulted in injuries.

Infection, prevention and control issues (IPAC) have been found for a second time at the home on Macklin Street North.

The inspection also claims food service workers were so unaware of residents' diets that a senior was served a meal known to make them sick.

However a new interim CEO - the home's third leader since March 2020 - says the issues are being fixed and she's bringing Shalom Village back to its roots of being at the forefront of seniors' care. The 127-bed facility was founded by the Jewish community and is part of a non-profit organization.

This is a place that is really doing the hard work of coming back," said CEO Pat Morden. It's not if you fall down, it's whether you can get up back up again ... and this organization, the board on down is getting back up again."

Leadership has been in upheaval during the pandemic with a revolving door of CEOs, administrators and directors of care. For much of 2020, Shalom Village was run by a dentist.

A provincial inspection in February alleged sexual abuse that went undocumented at the home, as well as a failure to do police checks on new hires. In addition, a number of IPAC issues were found, despite the home being in the midst of a COVID outbreak for the majority of the inspection.

While inspections are posted online, the troubling findings didn't become widely known until The Spectator reported on it in April.

You were worried when you read that stuff and I was worried sitting in my living room, too," said Morden. It wasn't OK."

Morden was the CEO of Shalom Village from 1989 to 2011 when she left to live on a farm she owns near Owen Sound. In the wake of the inspection, Morden was brought back in mid-July as a coach for the leadership team and named interim CEO in mid-September.

This is a place I love," said Morden. We've had a tough time ... We're owning it."

However, just before she took the helm, a second inspection found troubling results - 16 written notifications regarding areas of noncompliance with the Long-Term Care Homes Act.

The Ministry of Long-Term Care inspection, carried out on multiple dates from Aug. 11 to Sept. 1, resulted in one compliance order stemming from allegations of abuse and neglect involving consent and pain management issues.

Some of the allegations in the inspection report dated Oct. 31 are similar to what was found in February.

In addition, the report revealed the home didn't comply with an order from the February inspection to train all staff by May 2 on the province's zero tolerance policy of abuse and neglect of residents.

We've got lots of hard work to do," said Morden. But she also emphasizes much has changed since the August inspection.

I look at that and I say, That was then,'" she said.

One of the most stark similarities is that the inspector found 10 staff members hired between May and July did not go through proper checks.

Over the course of the pandemic, the province has allowed homes to hire staff while police checks were pending. However, the new hires are supposed to sign declarations that list any criminal charges, orders or convictions as well as findings or proceedings around misconduct.

However, no declarations were done until July 21, despite the inspection in February flagging issues around police checks. The PSW at the centre of sexual abuse allegations in the first inspection hadn't been properly checked by the home.

That's our fault," said Morden. We needed to pull up our socks in some of those areas. We've done all that."

The home is again blaming some of the most troubling issues on a single staff member. In the first inspection, it was the PSW who had already been terminated by the time it was reported on in April.

The new abuse allegations involve a staff member who Morden says, Should not have been working here and is no longer working here."

We took serious action, took it seriously," said Morden.

The staff member is alleged to have given a resident medication despite the senior adamantly refusing it. The inspector found documentation validating that the resident didn't need the medication that was supposed to only be given when required.

The resident was noted to be very upset and in distress over the situation," stated the inspection. Formal complaints were made to the home by the resident and family.

Another resident was alleged to have been frequently denied pain medication by the staff member.

We get people who come to us who don't have the same values as we do and we try to weed them out," said Morden.

The resident and family members complained about the pain medication being withheld but the inspection found no investigation was done.

Failing to investigate allegations of neglect may have placed the resident and others at risk," stated the inspection.

The inspection also found that it took five days for the director of care to report the other accusation of medication being given without consent.

In addition, the inspection claims a resident alleged they were physically harmed three times but no investigation was done despite a charge nurse being informed.

It's hard to rat out your friends," said Morden. You think about your friend and what it's going to mean if they lose their job. So we've had lots of conversations with the staff, reminding them that our duty is to the residents."

The home was ordered to give the problem staff member education on what constitutes abuse and neglect as well as residents' rights, consent and pain management. It was also ordered to ensure allegations of abuse and neglect against a specific resident are immediately reported and investigated. Lastly, the director of care and their assistant were ordered to review the home's policy on mandatory reporting.

In addition to the allegations around delayed reporting of abuse, Shalom Village was also accused of failing to immediately report an unexpected death. It's listed as one of the reasons for the inspection. The other reasons were to a respond to a complaint as well as followup from the last inspection.

The death occurred after the resident was sent to hospital because of a significant unexpected change" in their health. The inspection claims the director wasn't immediately informed about it and Shalom Village waited two days to put the death into the province's critical incident reporting system.

Morden says the death occurred before she was brought in as interim CEO. She says the hospital called the coroner to determine the cause of death and that Shalom Village staff didn't know why the resident had suddenly become so ill either.

They were waiting for the coroner to say, is this an unexpected death," said Morden about the delay in reporting it to the system. They should have just put it in. We still to this day do not have an update (from the coroner)."

The inspection also found failings when it came to an altercation between two residents that resulted in injuries - none bad enough to require hospitalization. Both residents had a documented history of this type of behaviour.

A review of progress notes showed no evidence of a behavioural assessment completed for either resident, including identified triggers, strategies, and interventions," stated the inspection.

Morden says the home now has a team of staff dedicated to issues with behaviour related to dementia, and a good way of tracking what is being done for these residents.

She also says the home has put the right staffing in place to deal with IPAC issues found in both inspections. The latest report found Shalom Village had no staff member leading IPAC and wasn't doing audits every two weeks - instead there were as many as 14 weeks between audits.

In addition, the inspection flagged concerns about food service workers being unaware of residents' diets, preferences and special needs. During a meal, a resident approached the inspector to express concern about being served a food that was known to make them sick despite it being written in their care plan as off limits.

In a second case, a resident had specific nutritional needs related to a health condition that weren't being met despite several complaints from the senior and their family.

Morden said she was working on improving communication with families and residents to fix this issue.

I can't say that we won't make mistakes," said Morden. What I'll say is we're going to act swiftly."

She says the changes are already making a difference at the home to the point that Shalom Village is recruiting workers again and is no longer desperately short staffed. She gives credit to those who worked double and triple shifts to keep it afloat until now, and has started initiatives to help them heal from the experience.

I've seen these courageous, passionate staff who stayed," she said. Despite it all, stayed because they cared about Shalom and the residents who lived here."

Joanna Frketich is a health reporter at The Spectator. jfrketich@thespec.com